2916 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION PERMIT NUMBER
aDILDING APPLICATION & PERMIT1. 2 916
ADDRESS/ ^ &Lbb. Rel . _ _ _ _ _
U1VJl BUILDING — ELECTRICAL—PLUMBING—MECHANICAL
OWNER'S PLAN CHECK VALIDATION
NAME QTY. ELECTRIC PERMIT FEE
PNON
CDNTRACTOR'S /�s^ OUTLETS-SWITCHES-RECEP 5.00/1.00
Amrusm.� W. _u,....J,3J8D3 ILIGHTING FIXTURES 5.00/1.00
CONTRACTORS PPLIANCES-RESIDENTIAL 4.00 -'
0
Mml/as a F%1,PHONE I IQ PANELS. 5.00 DATE OF APPLICATION
ARCHITECTSIGNS 600 PLANCHECK FEE P.C.NO.
OR .
ENGINEER
LIC.NO. SIGNS TRANS. 3.00
AARCH,OR
DDRESS ENG SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ZIP EMP.METER OR POLE INS. 15.00
AOGRESS
(—'
A MOTORS SEE FEE SCH. J
OR
SERVICE CHANGE 10.00
w
00 LICENSED CON"f RACTORS DECLARATION EE 1
a uU I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE DATE
to 4 n (commencing with Section 7000)of Division 3 of the Business and BLDG. ELECT. PLR
G. MEC .
H o i Professions Cod•,a d ny license is in full for
Z o`� Licen C'ss Lic.Numbe ❑ ❑ ❑
O Z H D Dale Con[actor
¢ y f BUILDING PERMIT
¢ tc w OWNER-BUILDER D17CLARATION INFORMATION
w o n H 1 beret affirm that I am exempt from the Contractor's License MISC.— REFER TO ORD
Y P VALUATION $/FT.
F u o ¢ Law for the following reason.(Sec.7031.5,Businessand Professions PERMIT ISSUANCE 6.00
„INJ Code:Any city orcounty which requires a permit to construct,alter,
ELEC.CONTR. LIC.NO.
Q E ¢ improve.he applicant
nt repair any sticture,prior to its issuance,xt.( ELEC.
i — u requires the applicant for such permit to Ne a signed statementisLithat TOTAL �A PERMIT TO
E
$ he is licensed pursuant to the provisions of the Contractor's License
F Z,i Law(Chapter 9(commencing with Section 7000)ofDivlsion 3 oftite
¢ Business and Professions Code)or that he is exempt therefrom and OTY. PLUMBING PERMIT FEE
¢ r $ the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TYPE CONSTR.
u3— by any applicant for a permit subjects the applicant to ucivil penalty ALTER-DRAIN -WATER IEA.) q,00
of not mom than five hundred dollars($500).1:
❑ 1,as owner of the property,or my employees with wages as BACK FLOW PROTECT.DEVICE 2.00 OCC.eaouP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale(Sec. 7044, Business and Professions .DRAINS-FLOOR,ROOF,AR EA,COND. 4.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES-PER TRAP 4.00 SD.FT.FLOOR AREA TOTALACREAGE
-nentslre not intlOorgh ended
ownemployees,for
rsS provided ever thinmldin GAS-EA,SYSTEM-I 4,00
!cents are noon scnded oroffcrcd(orsalc.If,however,the building
or improvement is sold within one year of he did lot the owner- GAS-EA.SYSTEM-OVER 4 IEA.) 1.00 BUILDING USE
builder will have the ble.). f moving that he did not build or im- - RES IND CON PB Other
Prove 1,aso nee of sale.). INDUSTRIAL WASTE INTER. 20.00
❑ d as owner of the property,am project
contracting with ❑ ❑ ❑ Cl ❑
licensed contractors to construct the project ISec. does Business LAWN SPRINKLERS.1 INC 5 V.B. 5.00 ASSESSORS PARCEL NO.
and Professions Code:The who
builds o License law does not apply
to tr owner of property who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5(EA.) 1.00
contracts for such projects with a contrndorl sl licensed pursusnt In
the Contractor's License Law. SEWER-SANITARY-STORM EA.200ft/8.00 TRACT NO, PARCEL No.
❑ I am exempt under Sec.—,IL&P.C.for this WATER HEATER W/VENT 4.00
reason
Dale Owner - WATER SYSTEM 4.00 ACC.DATE ACC.FILE NO.
WORKF-RS'COMPENSATION DECLARATION WATER TREATING EQUIP. 4.00
I hereby affirm that I have a certificate of consent to self-insure, ZONING ENG.SITE NO.
Or a certificate of Workers'Com nsation Incur nee,or a ce�fill, d
copy Iher f�• o Lab.C.`�� I I1S. r.-�
Policy N 0,L a Lab.
Q ❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
p/Ce lif•d copy I filed with219,; city inspection division. MISC.-
CC
ISC.- REFER TO ORD.
Z
ZZ APPlicant�6e_ , ❑ N❑ Y ❑ N❑CCPERMIT ISSUANCE 6.00 ]__�
OOD ZONE A.L.U.C.
CCRTIFICATIi OP EXEMPTION PROM WORKERS'
W >_ COMPENSATION INSURANCE PLG.CONTR. LIC.NO. PLG.
d 0 (This section need not be completed if the permit is for one TOTAL Y E] N❑ v [D N❑
Z hundred dollars($100)or less.)
U O I certify that in the performance of the work for which this per- DTV. MECHANICAL PERMIT FEE FEE SUMMARY
LL 6mit is issued,I shall not employ any person in any manner so as to
U become subject to the Workers'Compensation Laws of California.
- y Date Applicant ALTER OR ADD TO ME 4.00 BUILDING
} t9 NOTICE TO APPLICANT: If,after nm king this Certificate Of Ex-
Z emption,you should become subject to the Workers'Compensation APPLIANCE 4.00 PLAN CHECK
provisions of the Labor Code, you mustforthwith comply with FEE '
C..1 such provisions or this permit shall be deemed revoked AIR HANDLING UNIT( 1 GF ,00
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT 10 C. . .00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WI • D .00
the Performance of the work for which this permit is issued(Sec. MICROFILM
3097,Civ C.). - HEATING UNIT(TO 4,00
Lender's Name
Lender's Address HEATING UNIT(OVER 100,000 B.T.U.)7.50 ELECTRIC
I certify that I have read this application and state that the above VENTILATION FAN (SINGLE) 3.00
information is correct. I agree to comply with all city and countyPLUMBING —
Ordinances and state laws relating to building construction, and BOILER-COMP(3 H.P.or 100,0008.T.U.) 4.00
hereby authorise representatives of this city to enter upon the 801 LER-COMP (Over 100,000 BTUI SEE FEE SCH. MECHANICAL /
above-mentioned property for inspection purposes,
(We) agree tD save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
-Cupertino against liabilities,judgments, costs and expenses which PERMIT ISSUANCE 3.00 CONST.TAX _
- "may in any way accrue against said City in consequence of the
gra ing of[his per MECH.CONT. LIC NO. MECR. -
D 43 p 'y TOTALI TOTAL
store, Applicant/Contractor 1 Date
- OFFICIE COPY